Transcript
Announcer:
This is DermConsult on ReachMD. On this episode, we’ll hear from Dr. Shannon Trotter, who’s a board-certified dermatologist, Clinical Assistant Professor at Ohio University, and principal investigator for clinical trials at DOCS Dermatology Group in Ohio. She’ll be discussing clinical clues that can point to generalized pustular psoriasis, or GPP for short. Let’s hear from her now.
Dr. Trotter:
The clinical features that should prompt clinicians to suspect GPP—there's three main phases that really help you with understanding the clinical features. The first phase we talk about is the pre-pustular phase, followed by the flare phase, and then finally the post-flare phase.
So the acute flare phase is what most people think of with GPP. So this is the most dramatic and emergent. The patient might have a history of plaque psoriasis. They might have a history of possible trigger for GPP, like oral steroid use or potentially even infection. But when these folks come in, they're sick. They're systemically ill. They have high-grade fever, potentially chills. They might have malaise or anorexia. They definitely don't look well. Then, of course, they have cutaneous symptoms or changes in the skin that we associate with GPP, and that can be erythema, scaling, desquamation of the skin, and of course, those pustular lesions that we think about with GPP so classically—that could be individual or even coalescing into great lakes of pus.
Now, surprisingly, they can also have mucosal findings, which sometimes isn't talked about. They could have geographic tongue or fissured tongue. They might have inflammation of the lips or cheilitis, and you can also have ocular involvement with GPP, like conjunctivitis, uveitis, or even iritis. And then beyond the skin, you can also have involvement of the nails. They could have joint pain. If there's liver involvement, they might be jaundiced as well. They can have swelling of the lower extremities. And then, of course, finally, some implications there are the life-threatening complications we can see during that acute or flare phase, where patients could have heart failure, they could actually be septic, and they often require emergency care. So those are some of the key features you think about with that acute flare phase.
Now, other features to think about with GPP you might not think about are beyond that flare phase. So after an acute flare, patients enter the post-flare phase. And this is something we don't always think about a lot, but it really highlights how GPP is chronic. Now, in that post-flare, or what I like to think of as more of that chronic phase of GPP, patients may have skin involvement still. They could have erythema or potentially scaling, but on much less of a scale—not as grand or dramatic as during that acute or flare phase. And then they also may report systemic symptoms sometimes. They might report still that they have arthralgias, which can be hard to distinguish from psoriatic arthritis. They might report fatigue, and then often they'll complain of anxiety. During that chronic phase, patients are afraid. They're anxious about the possibility of flaring again.
And then the phase I really want everyone to focus on too and remember is the pre-pustular phase. This is the one with clinical features that can be sometimes difficult to diagnose GPP in. This can actually occur even years before that acute phase flare, and I think a lot of people just aren't familiar with this actually being a clinical component of GPP. During that timeframe, a patient may come in and already have history of psoriasis or classic plaque psoriasis, or they may have little skin involvement. And so it's that pre-pustular phase too that is hard to define but something we need to put on our radar. We often think GPP is the worst-case scenario, and it can be and often is that emergent when a patient comes in. But patients, during that acute or flare phase, can actually be a little bit milder on the spectrum. So GPP can actually be a spectrum within those phases. And so not everyone presents as severely as you might suspect. The problem with that is it can complicate things and it makes GPP overall harder to diagnose.
Announcer:
That was Dr. Shannon Trotter discussing key features of generalized pustular psoriasis, or GPP. To access this and other episodes in this series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
